Healthcare Systems Midterm
Terms
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- capitation
- fixed payment to HCP per member per month
- moral hazard
- having insurance means we consume more than we would if paying out of pocket
- national health insurance
- financed by gov't, delivered privately, i.e. canada
- national health system
- financed and delivered by gov't, i.e. great britain
- socialized health insurance
- financed through gov't via mandatory employer/ee contributions, private delivery, sickness funds, i.e. germany
- utilization
- quantity of healthcare consumed
- demand-side rationing
- production of healthcare depends on consumers' willingness and ability to pay; market justice
- deontology
- it's individual's duty to do what's right; ignores societal responsibility
- market justice
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1. emphaisis on individual
2. healthcare is distributed through supply-demand,
3. based on ability/willingness to pay, 4. no gov't interference - social justice
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1. healthcare distributed by gov't
2. societal responsibility
3. need based rather than ability to pay - utilitarianism
- greatest good for the greatest number; ignores the individual
- 6 payers in the healthcare system
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Medicare
Medicaid
BC/BS
Commercial companies
VA
Tricare - 3 things that shape today's economics of healthcare
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uniformed consumer
perverse incentives
intermediaries - 4 ways technology has an impact
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drugs
imaging
surgery
genetics - 3 major health indicators
-
life expectancy at birth
life expectacy at age 65
infant mortality - 5 challenges to US healthcare system
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1. no central agency
2. access based on coverage
3. imperfect market
4. multiple 3rd parties
5. legal risks influence practice - community rating=
- premium is based on utilization in geographic region- healthy people pay for sick people
- experience rating=
- premium based on demographics or experiences
- Blue Cross/Blue shield: which is hospital and which is physician
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BC- hospital
BS- physician - key differences between non-profit and for profit
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Non Profit: governed by community boards, owned by the community, tax exempt
For Profit: has shareholders, excess revenue beyond expenses doesn't have to go back to institution. - who finances/operates medicaid?
- financed by federal and state, operated by state
- who finances/operates medicare
- federal for both
- who's eligible for medicare
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>65 y.o
ESRD
disabled - who's eligible for medicaid
- below the poverty level- $9800 individual or $20,000 for family of 4
- what year were medicare and medicaid established
- 1965
- What does part A medicare cover?
- hospital expenses, no nursing home coverage
- who pays for Medicare part A
- it's included for free- automatic coverage
- what does MEdicare part B cover
- supplementary- physician, outpatient, DME
- who pays for part B
- Medicare pays 80% of "assigned" rate and pt. pays 20%
- what is assignment
- docs agree to a predetermined rate set by medicare- which may be lower than the going rate
- What does medicare part c (Medicare + choice) cover?
- MCO participation
- who pays for part c?
- Medicare pays 95% of the community rating; only for very healthy elderly people
- what does part d cover?
- prescriptions
- do medicaid participants pay a premium?
- no
- what is managed care?
- insurers and providers collaborate to use financial incentives to alter provider/patient behavior to lower costs and increase effectiveness
- what is retrospective payment
- provider receives a payment after services have been provided
- what is prospective payment
- provider recieves payment before-hand, regardless of services rendered
- which type of payment offers incentive for providers to keep pts healthy
- prospective
- with capitation, who does the risk lie with
- providers
- 3 keys to success with MCOs
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Limit:
1. hospital stays
2. ER usage
3. specialists - 3 types of cost-sharing
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premiums
deductibles
co-payments - what is stop loss provision
- the maximum out of pocket liability an insured person pays in a given year
- What are the types of MCO's?
- HMO, PPO, EPO, POS
- whats the most common type of MCO
- HMO
- what distinguishes HMOs from other types
- wellness care, capitation, and using in-network providers
- describe the staff model HMO
- an HMO employs its own fixed salaried docs, i.e. puget sound
- describe group model HMO
- HMO contracts with multi-specialty group practices to provide comprehensive services, i.e. Kaiser
- describe network model HMO
- HMO contracts with more than one medical group practice, i.e. Health Insurance Greater NY
- describe Independent model HMO
- independent docs form groups that contract with HMOs
- which model of HMOs is most common
- IPAs
- what's the relationship between choice, cost and provider control
- the more choice, the higher the cost, and the less provider control
- distinguising features of PPOs
- can pay higher fee for out of network providers if you want, and arrange discounted fees with providers rather than capitation
- What is a POS plan?
- a hybrid of a PPO and HMO- free choice of providers, increased out of pocket costs, and tighter utilization
- 3 key measures of health care
- access, quality and cost
- what are barriers to access
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1. Financial- lack of insurance
2. Structural- shortage of doctors, needing referrals,etc.
3. Personal- religious, cultural - what is the 10/90 gap
- 10% of the worlds population uses 90% of all healthcare resources
- what are key indicators to look at when comparing healthcare systems
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-population health
-inequalities/disparaties
-system responsiveness
-distribution of responsiveness
-distribution of financial burden - what are the 4 varieties of healthcare financing globally
-
-out of pocket
-individual private insurance
-employment based private insurance
-government - financing in Germany
- govt' mandated, employment based private
- delivery in Germany
- mostly private
- financing in Canada
- gov't
- delivery in Canada
- mostly private
- financing in UK
- gov't
- delivery in UK
- public
- financing in Japan
- gov't, some employee contributions
- delivery in JApan
- mostly private